Friday, September 4, 2015

Nurse Life Hacks

In my opinion, there are 3 elements that can make or break a nurse’s 12 hour shift; the behaviors of his/her patients, the neediness of their family members and the overall health and well-being of the nurse. I have been a nurse for almost 10 years and have finally come to a place in my career where I can say that 90% of my shifts are relatively stress free. I attribute this stress free nurse life to a few things; working night shift, sleeping plenty, not taking things personal, and developing certain routines that I can apply to all of my patients; because working nights and sleeping may not be an option for some of you, I have developed a few “nurse life hacks” that everyone can incorporate into their daily nursing lives.
The number 1 priority to improving your nursing life is to prepare yourself for a long day’s work:
-          Buy enough groceries and cook enough food to last you for all of your shifts. You will be eating leftovers for 3 days but I guarantee it will be healthier and cheaper than buying food at work.
-          Eat long acting carbohydrate foods such as fruit, vegetables, brown rice, beans, whole grain breads and sweet potatoes while at work to prevent from hitting that dreaded 3 o’clock wall. This is especially important for night shift workers.
-          Make sure you eat throughout your shift. Take 5 or 10 minutes in the morning and evening time to grab a quick healthy snack. This will help keep your blood sugar steady and you feeling good throughout the day.
-          Fill your water bottle before you get report so you don’t find yourself taking your first drink of water at lunchtime.
-          When you get home from work stick your whole lunch bag, Tupperware and all, into the refrigerator; this way you don’t have to wash any dishes. You can just refill your Tupperware with the same exact food you had in it the day before.
-          If you are having a hard time with the night shift schedule, try working 1 night, taking the next night off and then finishing your last 2 shifts or vice versa. You will find that you have more time for the gym, sleeping or whatever else you do on your time off.
Taking care of patients with certain diagnoses can be a challenge some days. Developing a routine on how you approach these patients will improve the quality of your life and the patients all at the same time.
-          For patients dealing with pain, I recommend setting up a pain schedule immediately upon introduction. If it is a chronic pain patient make sure you tell them exactly what you will be giving them and when. Write it down on the whiteboard and stick to the schedule. As long as they know you are coming with their Dilaudid they won’t call you every 5 minutes. For regular patients with pain, ask them what they take at home and if they would like to be woken up for a pain assessment. Remind them to not let the pain get out of control.
-          If you have a restless patient, try giving them Tylenol and a bath before bed. I have found that this combo helps people sleep.
-          For your unruly alcoholic patient who needs sublingual Zyprexa, get a mouth swab wet, stick the Zyprexa to the swab and insert into patient’s mouth. This prevents any unnecessary biting.
-          If you work in the ICU, a good way to remember which drips require a weight with calculation, you can think of the 3 D’s; Dopamine, Dobutamine and Diprovan.
-          Do hourly rounds. I’m sure you have heard this from administration and you find it really annoying but trust me it works. Peaking your head into your patient’s rooms every hour, and if they are awake, asking them if they need to go to the bathroom or need anything else, prevents falls and call lights.
-          Chart at the bedside as much as possible so you don’t forget anything and you refrain from using your body as a notepad.
-          Make a plan with your CNA at the beginning of your shift, especially, if you have total care patients. Talk about your turning schedule and when you will be bathing them.
As far as patient’s family members go:
-          Keep your patients looking clean and comfortable. Nobody wants to see their loved one all disheveled or with blood on their sheets. Put a sheet over them regardless of their temperature. Modesty is important to most people.
-          Take 2 minutes at the beginning of your shift to introduce yourself and discuss the plan for the night. Most family members will go home once they know their loved one is in good hands.
-          Be open to answering questions no matter how trivial they seem to be. Family members like to be involved and know that you have the patience to teach them.
-          Fill out the whiteboard with all of the answers to questions that someone might ask. Even if your patient is incapacitated, the family can still read.
-          Keep the room clean.
Learning tricks on how to insert foley catheters and NG tubes is an interesting and important part of nursing, however, I believe in the larger scheme of things, establishing a routine in your daily nursing life is a much more effective way to save time and energy. Establishing a routine will not only greatly improve your job satisfaction but will also help improve the quality of life of your patients and their families. As far as learning how to not take things personally, I think the Serenity prayer just about sums it up: “God grant me the serenity to accept the things I cannot change; courage to change the things I can; and the wisdom to know the difference.” There will be people in your personal and professional lives who just don’t care that much about themselves or their situations and there is nothing you can do to change that. All you can do is accept them for who they are and treat them with kindness.

Tuesday, October 14, 2014

Feeling Overwhelmed

Have you ever had a moment in your career where you just wanted to cry and quit? I know for sure some of you nurses had those in your early years... it's okay you are not alone. I often have patients ask me if I like my job. I tell them in the beginning I did not, but I have learned to ignore the politics and just take care of my patients. The problem now is that the politics have become so invasive that I can no longer ignore them. When I graduated nursing school I remember thinking to myself "how in the world am I going to remember all of this information, babysit doctors and pharmacists, not become upset when my patient calls me names and tries to assault me, remain confident when my co-workers doubt my skill level, chart every damn thing that I do, and not get overtime?" With time I can say that I have learned to juggle most of these things but now it is coming to a point that every time I go to work or check my email, there is another task for me to do. I feel like I am at my limit and unless there are some major changes that occur in healthcare, I will have to pick and choose what I think is the most important because I cannot do them all.

  • If you want me to have excellent customer service and treat patients with utmost compassion and empathy, then give me time to do this. I cannot enter a woman's room, who is crying because she has just been diagnosed with a terminal illness, in a hurry because you chose to give me an admission at shift change. What do you expect me to do "sorry ma'am that your life is about to end and your family has left for the day but I have to admit my other patient. Hopefully I can make it back here in the next 2 hours to comfort you. In the mean time you can listen to this channel that plays birds chirping and waves crashing to make you feel better." STOP GIVING NURSES ADMISSIONS AT SHIFT CHANGE. I don't care how you do this but figure it out. We can save people's lives for god's sake. 
  • I know hospitals are freaking out because reimbursement is becoming more difficult and it has become absolutely vital to chart on core measures and other JAHCO mandates in order to get paid. We all want to get paid, trust me. IF IT'S THAT IMPORTANT THEN HIRE SOMEONE TO PERFORM THESE SPECIFIC TASKS. Why is it up to me to make sure every patient with a heart attack is prescribed a beta blocker or to make sure the physician has charted in his note that someone is at low risk for DVT. I barely have enough time to worry about my own charting let alone the physician's. 
  • Some genius has created what is called the "no pass zone," This means that every person who works in the hospital cannot walk past a call light and not answer it. This sounds great in theory but I don't think I have ever seen a non-clinical person answer a call light. If you want call lights answered faster, then HIRE MORE CNA'S AND GIVE THE NURSES LESS PATIENTS. If patient satisfaction is that important then it is worth the extra staff. 
  • Taking care of patients with chronic pain and narcotic addiction is becoming commonplace. These patients require specialized treatment. They should be managed by a pain service of some sort and dealt with very carefully by nurses who have a good understanding of pain control. They should not be left on the medical floor with a nurse who has 5 other patients. This is not fair to the nurse or the patient. In the name of patient and nurse satisfaction, STICK CHRONIC PAIN PATIENTS ON FLOORS WHERE THEY CAN BE MANAGED APPROPRIATELY. 
Nurses come to work everyday prepared for the worst and expecting to be at their best. Administration needs to realize that we cannot perform the way you want us to under the current conditions. If you want higher quality of care, increased patient satisfaction, less falls, higher reimbursement and happy nurses then changes need to be made. It should not take an Ebola outbreak to help us realize that our standards are not up to par. I am proud of the nurses who have verbally supported Nina Pham when her own government threw her under the bus. We as nurses have to support each other. We are in the trenches taking care of these people while administration sits in their offices pointing fingers and placing blame; if you really want to improve the quality of care delivered by your healthcare system, then I challenge you to come out of your office and get your hands dirty.

Wednesday, September 3, 2014

Narcotics are Not the Answer

Effective pain management has become increasingly difficult these days. There seems to be a lack of understanding of the dangers of narcotic pain medications among the general population and many of my patients and their family members. The biggest thing I want people to understand is that these medications CAN KILL YOU. That is right, they can kill you in multiple fashions. According to Sanjay Gupta's recent article on
every 19 minutes someone in the United States dies of an accidental PRESCRIPTION drug overdose! This is now the leading cause of accidental death in America, even above car accidents. What the hell is going on? Not to mention that many of these people have been turning to heroin because it is cheaper than prescription pills; talk about a gateway drug. The next time you lecture your kids about smoking pot and then head into the bathroom and take a Percocet for your back pain, you may want to think twice about what you just said. 
I think what America is failing to understand is that pain is a part of life. If you come into the hospital and have a surgical procedure, there will be pain; you just had your body cut into with a scalpel and possibly had some organs removed, it's gonna hurt. Pain tells us that there is something wrong. We should not mask the pain with narcotics, how else are we going to know if you are getting better. Not to mention that being constantly sedated can lead to pneumonia, blood clots and other life threatening conditions. It is in your best interest in life and in the hospital to remain as awake and fully functional as possible, despite the pain. We will not let you lay there agonizing and miserable, nurses are extremely good at being able to take the edge off without killing you or sending you into respiratory failure. I think our society has created a "quick fix" mentality and people expect it everywhere they go. We have forgotten that there are alternatives to treating pain; narcotics should be the last resort. 
  • If you are admitted into the hospital for any type of surgical procedure please ask your doctors and nurses what level of pain should be expected and how they expect to manage your pain. If you have surgery anywhere in your torso it will become increasingly important to focus on deep breathing and coughing to prevent yourself from getting pneumonia. The single most important thing you can do to prevent pain with these types of surgeries is to "splint" your incision with coughing and any type of movement. "Splinting" means that you hold pressure on the incision with a pillow or rolled blanket while you perform these activities. You can ask for non-narcotic pain medications as the first line of defense. If you still are having too much pain that prevents you from coughing and deep breathing then go ahead and ask for stronger pain meds. 
  • People who take narcotics will be constipated. The narcotics slow down the motility in your intestines. The first thing you should do is cut down on the narcotics, the second thing you should do is drink more water and then exercise to increase your motility. The first thing I tell my surgical patients to do is get up and go for a walk. This also decreases the chances of getting a blood clot. 
  • If you are having a lot of knee, ankle or back pain your first resort should not be to see a surgeon. Maybe it is time to lose some weight. People assume that because they have these pains and they have a hard time exercising, that they cannot lose weight; this is not true. You can lose weight by changing your diet alone with no exercise. 
  • There has been a rise in the last few years in the incidence of arthritis and osteoporosis. There is much evidence to support that diets high in protein and animal products lead to inflammatory diseases such as arthritis, eczema, and even asthma and are also one of the leading causes of osteoporosis. Decreasing the amount of animal products and increasing the amount of vegetables, legumes and whole grains in your diet is enough to decrease the inflammatory process in your body and relieve pain. Weight bearing exercise, even in the elderly, have been shown to improve bone health. Annemarie Colibin's book The Whole Food Guide to Strong Bones is an excellent resource for those looking to increase their bone health. 
  • People with chronic back pain should consider yoga,massage and acupuncture as an alternative pain management regimen to narcotics. These are not quick fixes, but they have virtually no side effects and will leave you conscious. Medical marijuana has become increasingly popular and proven effective in many conditions such as migraines, chronic pain, seizure disorders and improving appetite. I can honestly say that I have never taken care of someone who overdosed on marijuana. 
  • If the pain you experience is of an emotional source, then I can tell you now that the road to recovery is not going to be a "quick fix." If you never get to experience depression at its fullest then you are denying yourself the opportunity to realize exactly what it is that needs to be changed to make your life better. Depression forces us to be alone and be stuck in our heads. Its purpose is to help you focus on yourself. If you use narcotics, alcohol or other drugs to numb your depression, you will never get better. The first step is to kick the substances with whatever help it takes. The second step is to seek long-term happiness through good social and family connections and find a purpose in your life outside of yourself; what can you do to improve the world that you live in?
There are many sources of pain in this world whether it be from a surgical, physical, or emotional origin. Pain is a part of life and it serves a vital purpose in reminding us that we are human and we are mortal. It is often a friendly reminder that life can be short and that we should savor what we have because you never know when it will be gone. Using narcotics to mask pain is a highly dangerous practice that medical professionals and the community should be aware of. Narcotics should be a last resort in pain management. It is important to protect yourself from the "quick fix" system by informing yourself and demanding pain management alternatives from your physician. 

Tuesday, July 22, 2014

Family Matters Part 2: A Guide for Patient's Families

Being in the hospital is not only stressful for patients, but it can also take a toll on family members as well. There is much evidence to support that involving patient's families in their care not only reduces the level of stress of the patient and family, but also aids in decreased lengths of stay and higher patient satisfaction (you can Google "patient family centered care" and read whatever scholarly articles you wish if you don't believe me). As a nurse, regardless of whether or not you believe in patient centered care is irrelevant; patient satisfaction is where it's at. I can tell you that the the current hospital system I work for as well as many others I have encountered, are focusing more on patient and nurse satisfaction more than ever before. Many hospitals have opened visiting hours to 24 hours a day, have started purchasing cots for family members to sleep in, have developed and trained nurses to function as family support teams and have even begun throwing patient's ice cream socials upon discharge!!! (I don't agree with the last event, but if it makes em' happy...) The healthcare system is evolving, but the nurses themselves are lagging. I can tell you that we are doing our best to accommodate families but sometimes the family members themselves can be very difficult and un-realistic. I have come up with a few general rules that family members can follow to meet the nurses half way as we become better at delivering patient family centered care:

  1. If you are calling to check in on your loved one, please try to call after 8am or 8pm. Nurses usually give report to each other around 7am. This will allow us to assess your loved one before you call; this way we can give you a better idea of how they are doing. If you want to know how their night went, you can call before 6am to speak with the night nurse. 
  2. It is illegal for us to give people patient's information over the phone unless the patient gives us authorization to do so. Often times on admission, the hospital will provide you with a pass code that you will have to give us when you call before we can release any information to you. If you don't have the code, you don't get any info; and please do not hand out the code to everybody and their mother. Make one person the contact person and all other family members can call that designated person for updates. The more time we spend on the phone, the less time we spend in the patient's room. 
  3. When you are visiting your family member in the hospital, please keep the visitors to around 2 at a time, especially in the ICU (other floors might not care as much). There isn't much room in hospital rooms and there tends to be a lot of equipment.
  4. Especially in the ICU, check with the nurse before stimulating or engaging with your family member, especially if they have recently suffered a stroke, a head injury or are on a ventilator. Is is important that the brain not be overstimulated in order to heal. When patients are on ventilators, we like for them to be calm and relaxed in order for the ventilator to do its job. 
  5. Patient's are in the hospital usually because they are sick. I know sometimes family members feel like being with them all day so they are not alone is beneficial, but in reality a lot of patient's tell me to kick out their family members so they can sleep. Put yourself in their shoes, if you were at home sick in bed, would you want visitors coming to see you all day, probably not. It's okay to go home, even at night. If anything should happen, we can call you. 
  6. If you are with your loved one as they get admitted to the hospital from the emergency room, we will kindly ask you to step into the waiting room while we get the patient settled. This is a privacy issue. Often times we take their clothes off, look at their skin and go over some personal history questions. Some people don't want their family members in the room during this time. As soon as we are done, we will come and get you. 
These are just a few suggestions. The healthcare system is working on improving our patient family centered care practice. We will not perfect this overnight or even in the next decade. Be patient with us and kind. Express your concerns in a professional and courteous manner. Ask to speak to the charge nurse or family support team if you have concerns about your loved one's care. Most nurses love taking care of people, all people, including families, but we also like to be treated with respect. 

Tuesday, June 17, 2014

A Moment of Truth

To my most recent patient,

There comes a time in every nurse's career when he/she starts to experience what some folks like to call compassion fatigue. describes compassion fatigue as " fatigue, emotional distress, or apathy resulting from the constant demands of caring for others..." Now, I know you are probably thinking to yourself that I should find another job or that I need therapy or something, but what I'm here to tell you is that is not the problem. I personally believe compassion fatigue arises when we as healthcare providers are forced to be compassionate towards people who have no desire to help themselves or their situation; who are non-compliant with their medicines or therapies and are just plain rude and nasty people. I do believe that you are truly suffering but I don't believe that you are actually experiencing the pain you are describing to me. I believe your pain stems from a psychological place and cannot be fixed with your constant demands for dilaudid, zofran, percocet, benadryl, and valium. I am not the only one who believes this. Healthcare workers are familiar with manipulation and drug seeking behaviors. Unfortunately for both you and I, the healthcare industry is now so focused on creating the "best patient experience" that we as providers have now become enablers. Even though we know what's in  your best interest, we cannot tell you "no" in fear that we will be reprimanded for not treating your "pain" adequately. You as patients suffer because the root of your actual "pain" is never handled appropriately and when you leave the hospital you will most likely be addicted to narcotics. So if your looking for someone to blame, you can blame the healthcare system. If you looking for someone to fix the problem you are going to have to do it yourself. I advise you to seek the help of a mental health professional not a healthcare professional. We are not skilled in the areas of mental health. Our job is very demanding both physically and emotionally and most of us are not comfortable treating your mental pain with narcotics and sedatives. If all you want is narcotics then it is unnecessary to waste healthcare dollars on tests and procedures to locate your "abdominal" pain that you do not have actually have. I know this probably sounds mean and not very compassionate but its the truth.


Your Nurse

Tuesday, April 8, 2014

Family Matters - Part 1

I recently had a situation with a co-worker that I found particularly disturbing yet very eye opening. Let me explain... I recently took care of a man who was dying from end stage renal disease (kidney failure) at the young age of 57. He had 2 daughters ages 21 and 23 and a very large extended family. If you have had any experience working in or being in the ICU, you have probably noticed that the visiting hours are between certain hours, are usually limited to 2 visitors at a time and they never let anyone spend the night in the room. I have never really understood the rationale behind all of these regulations but you know how nursing is, once someone's done it a certain way for a certain time, God forbid you try to change it. I have never been a fan of limiting visiting hours or visitors so I have always just managed my visitors on my own; I usually just pull the curtain so the charge nurse can't see in my room (especially if you have one of those charge nurses who likes to micromanage you); anyway, so I asked my co-worker to come help me pull my patient up in bed. I had allowed 5 visitors in my room because the poor man was dying and they were very polite people so I had no problem with it. As my co-worker entered the room, in a very rude manner, she proceeded to tell my visitors they had to leave the room for privacy purposes, and then when they called her out on her rudeness, she threatened to call security on them!!!! I was absolutely disgusted at her behavior and shortly after had a conversation with her and the charge nurse regarding the situation. What I realized during that discussion is that the culture in the ICU surrounding the importance of family and healing was very negative and in desperate need of change.
I do understand where my co-worker was coming from. I use to work in a place where that mindset was the norm. I believe that culture was created as a result partially because of the patient population and because of learned behavior. Hospitals located in certain neighborhoods bring in a lot of drug overdoses, alcoholics, gang violence, and family drama. I know what its like to not want to deal with someone's personal family drama or have your unit on lock down because a patient's family members are holding you responsible for their loved one's death. I get it. I have had compassion fatigue before. Our job as nurses is emotionally and physically draining. Often times we don't feel respected by our leadership, co-workers or our patients so I can see how we become this way. In 12 hours it is highly unlikely that we will change our patient's family situation or even their physical condition, but what we can change is our mindset and this patient or family's experience.
Each time we fail to treat a patient or their family as individual or apply them to some standard, we lose the ability to be personable. We have to treat each patient situation as its own entity. Here are a few tips:

  • Allow your fellow nurses to manage their own visiting hours. If he/she has multiple visitors in his/her room then mind your own business; your co-workers are perfectly capable of managing the situation. 
  • If you have to ask a family member to step out of the room so you can turn them or clean them up that is fine, just make sure you say please and thank you and explain your rationale. 
  • If you have those family members who like to stare at the monitor and ask a lot of questions, then answer them to the best of your ability. If you don't have time at that moment, then politely say that you can't explain it now but that you will get back to them if you can or give the short version.
  • Avoid becoming defensive by becoming curious instead. If someone comes out to notify you that they think that there is a problem with their loved one's IV simply say "really?" "let me take a look at it". You can seriously use this response for everything. 
  • If a family member wants to cover up their loved one and this patient has a fever, it is okay to cover them with a sheet, I promise you it's not going to hurt anything. Most people are pretty modest. 
  • If someone is dying then do everything you can to accommodate this family. You can single handedly change the way this patient and their family experiences death. I know in healthcare we have become numb to death, but just so you know this is not normal, the rest of the world still thinks its a big deal. 
  • If you are dealing with a nurse who you notice does not provide respect and decency to patient's family members, then either bring it up to them or tell your manager. I think in most cases that these nurses aren't even aware that they are doing it.
  • Do your best to put yourself in this family member's shoes. Being in the hospital is difficult for both patients and families. How would you expect your mother, father, son or daughter to be treated?
The old mindset in the ICU is that we are too busy saving people's lives to stop and answer questions or get you a warm blanket, but the fact of the matter is that providing a quality patient and family experience and treating people with respect and common decency  is much more powerful than medicine alone. 

Wednesday, March 12, 2014

How to Easily Please your Patients and their Family

Whether we like it or not healthcare has now become a customer service industry. The days of kicking visitors out for "quiet time" and expecting patients to just do what you tell them and don't ask any questions are over. Healthcare is shifting to a more collaborative, holistic approach to taking care of patients with the ultimate goal being patient satisfaction. I hear many nurses, especially the seasoned ones, complaining about this approach to patient care and I can understand their point, a little. The old way of thinking, at least in the ICU, is that nurses are here to save patient's lives not pamper them; the hospital is not a hotel. While I do believe there are situations when patients are so gravely ill that really the main focus is on life sustaining treatment, the reality of the situation is that many of the people we care for are just in need of close monitoring. In the ICU especially, taking care of the family members is often the most challenging part of the job. Many patient's family members have been taking care of their loved ones themselves for many years; they can be protective and particular about their care. Watching someone you love suffer in both physical and emotional pain can be overwhelming for everybody, including healthcare workers. I think as healthcare providers we can be numb to people's suffering. Our job is demanding emotionally and physically. Spending 12 hours with someone who has inconsolable suffering is draining. Through my experiences in the ever changing world of healthcare and customer service, I have discovered some patient satisfaction practices that have made my work life a lot easier.

  • Utilize the white board - As an ICU nurse I use to think to myself  "why am I going to fill this out when the patient is on a ventilator or is too confused to even know they are in the hospital?" The fact of the matter is that patient's family members read that board too. Something as simple as writing your name and the general goals for your shift decrease the amount of questions significantly. I also like to form a pain management plan for patients during my first assessment and write down their pain medicine schedule on the board. For those of you who are in administration, the only time I feel like it is pointless to write on that board is when it is hidden in some random corner somewhere where no one can see it; so do us all a favor and move the boards into a more appropriate location. 
  • Don't take it personal - Many family members can come off as aggressive or rude. Sometimes you feel that they are questioning whether or not you are competent enough to care for their loved one. Sometimes they are just plain crazy. The best advice I can give you is to not take it personal. These people scared, overwhelmed, tired and stressed out. When they are bombarding you with questions or questioning your care, the best thing to do to prevent yourself from getting defensive is to become curious. When a family member tells you the foley bag is full and needs to be emptied (when it fact it just needs to be tipped) all you have to do is say "really?, let me take a look"; and then you do some education "oh, it drains over into the bag, but thanks for letting me know." There are cases when patients or family members are really crazy and in this case you ask them to leave politely and call security if need be. 
  • It's all about the look - Nobody wants to see blood stains on their bed sheets or gown. In the real world, outside the hospital, that's just plain gross. Keep your patients and their rooms tidy. Shaving someone and combing there hair can make a patient both feel better and look better. Try to keep them looking comfortable in the bed. I know this is impossible for some people, but do your best. 
  • Focus on the small things - Patient's family members tend to focus on the small things. This is their way of participating in their loved one's care. Just because your patient has a temp of 102 doesn't mean that you can't place a simple sheet over them. Most of the world is fairly modest when it comes to exposing their body parts. If it makes the family happy, cover them with a sheet. If you have family members that like to stare at the monitor, you can do a quick in-service as to what the numbers mean, what you are looking for and reassure them that you can see the monitors at the nurse's station. 
  • Education - Take the time to explain what you are doing and provide rationale to patients and family members before  you do something to them. Explaining to a patient or family member the importance of re-positioning to prevent pressure sores will most likely encourage them to want to participate in their care. 
These are just a few suggestions to make your shift a little easier. The nursing profession is so demanding and everyday I feel like we are being told to do more. If you can find a routine or practices to make you work life easier, it will make you happier; and when nurses are happier, patients are happier. The fact of the matter is that patient satisfaction does affect our profession. Patient's have a choice on which hospital they want to go to. If patients don't want to come to your hospital then guess what, you will be out of a job.